About the BoardBoard News and Policies > Guidelines for the Use of Controlled Substances in the Management of Chronic Pain

Dear Physician:

The New Hampshire Board of Medicine has adopted guidelines for pain management in hopes of fostering the best pain treatment for the citizens of this State. The Board encourages physicians to view effective pain management as a part of quality medical practice for all patients with pain, be it acute or chronic, due to either malignant or benign disease, and particularly when associated with terminal illness. For many physicians, fear of investigation or sanction for dispensing large or prolonged narcotic prescriptions has impeded effective and appropriate treatment. Accordingly, these guidelines have been developed to clarify the Board's position of pain control specifically as related to the use of controlled substances, to alleviate physician uncertainty, and to encourage better pain management. This format was derived from many sources including N.H. Physicians specializing in pain management, the N.H. State Medical Society, and the Federation of State Medical Boards.

Physicians should not fear disciplinary action from the Board or other state regulatory or enforcement agency for prescribing or administering controlled substances for a legitimate medical purpose and in the usual course of professional practice. The Board has concern in those cases where inadequate pain control results from either lack of current knowledge of pain management or inappropriate fear of investigation for providing narcotics where indicated.

The N.H. Board remains obligated under the laws of the State of New Hampshire to protect the public health and safety. The Board recognizes that inappropriate prescribing of controlled substances including opioid analgesics, may lead to drug diversion and abuse by individuals who seek them for other than legitimate medical use. Improper prescribing or documentation will continue to be investigated.

The guidelines are not rigid rules. They serve as a model for physician practice, and to communicate what the Board considers to be within the boundaries of professional practice. While the Board will likely not take disciplinary action against a physician for failing to adhere strictly to the provisions of this protocol, "significant deviation" from the guidelines will likely result in investigation and/or sanction of a physician practice. Key features of the guidelines include accurate documentation, some form of a treatment plan, acceptance of the plan by the patient, and appropriate evaluations and/or consultations. Compliance with all controlled substances laws and regulations is mandatory.

The Board will judge the validity of prescribing based on the physician's treatment of the patient and on available documentation, rather than on the quantity and chronicity of prescribing. The goal is to control the patient's pain for its duration while effectively addressing other aspects of the patient's functioning, including physical, psychological, social and work related factors. This Board hopes to encourage superior pain management by physicians, and clarify appropriate pain relieving practice with the institution of these guidelines.

Sincerely,

The New Hampshire Board of Medicine

1. Evaluation of the Patient
An accurate and complete medical history and physical examination must be documented in the medical record. The medical record should document the nature and intensity of the pain and relevant co-existing condition (including current or past substance abuse.) The results of relevant diagnostic studies, other evaluations and consults should be part of the record.

2. Treatment Plan
A treatment plan should state objectives that will be used to determine treatment success, such as pain relief, and/or improved physical or psycho social function. The record should indicate if any further diagnostic evaluations or treatments are planned. Other treatment modalities might include a rehabilitation program, physical therapy or the like, or other treatment plan deemed appropriate for the patient's treatment objectives. After treatment begins, the physician should adjust drug therapy to the individual medical needs of each patient.

3. Informed Consent and Agreement for Treatment
The physician should discuss the risks and benefits of the use of controlled substances with the patient, appropriate significant other, and/or guardian. The patient should receive prescriptions from one physician and one pharmacy when chronic narcotic use is adopted, and should authorize communication between both parties. Frequently, the physician may elect to use a written agreement with the patient, especially where risk of medication abuse is a concern. A written agreement may; (1) indicate a specific pharmacy and prescribing physician; (2) give permission for communication between care providers; (3) detail amount and frequency of medication and prescription refills; (4) define expected follow-up and participation in any other pain treatment activities; (5) provide reasons for which opioid therapy may be discontinued; (6) include an agreement to have urine/serum medication or drug levels/screens when requested ; and (7) document other inclusions appropriate for management of the individual patient.

4. Periodic Review
At reasonable intervals, the physician should review the course of opioid treatment and any new information about the etiology and impact of the pain. Continuation or modification of opioid therapy should depend on the physician's evaluation of progress toward stated treatment objectives. If reasonable treatment goals are not being achieved, despite medication adjustments, the physician should re-evaluate the appropriateness of continued opioid treatment. The physician should monitor patient compliance in medication usage and related treatment plans.

5. Consultation
The physician should refer the patient for additional evaluation and treatment as necessary and reasonable in order to achieve adequate control of pain and any other treatment objectives. Special attention should be given to those pain patients who are at risk for misusing their mediations and those whose living arrangement pose a risk for medication misuse or diversion. The management of pain in patients with a history of substance abuse, or with comorbid psychiatric disorder, requires extra care in structuring, monitoring, and documentation. When indicated and available, consultation with, or referral to, an expert in the management of chronic pain is advised.

7. Compliance with Controlled Substances Law and Regulations
To prescribe controlled substances the physician must be licensed in the State of New Hampshire, have a valid controlled substances registration and comply with federal and state regulation for issuing controlled substances prescription. Physicians should refer to federal, state and local regulatory agencies for guidance, by writing the Board of Medicine, 121 South Fruit Street, Suite 301, Concord, New Hampshire 03301.